Emergency Medical Dispatch
NAEMD Case Study
Fall vs. Collapse: A Dilemma in Dispatch Decision-making
By Jeff Clawson and Brett Patterson
National Academy of EMD
For our readers who use the Medical Priority Dispatch System, 9-1-1
Magazine presents this educational
Case Study contrasting the use of
Protocol Cards 17 and 31 as they
pertain to unwitnessed collapses.
s we gradually evolve from the
art of medical dispatching
toward the science of it all,
reliable and applicable patient
outcomes are being used to
f ine-tune the National Academy’s
Medical Priority Dispatch System
(MPDS). New, previously unavailable
data linking scene findings of cardiac
arrest with MPDS dispatch codes are
providing us with new insight into dispatch decision-making. One of the more
vexing dilemmas has been discerning
Falls vs. Sudden Unconscious as the
Chief Complaint when the patient is
reported to have fallen or collapsed, but
when the event itself was unwitnessed.
A case provided to the Academy by
an Accredited Center has shed light on
the necessity to ref ine our thinking
behind the selection of the correct Chief
Complaint regarding these types of calls.
The initial transcript of the case begins
as follows:
Caller: My husband has fallen in the
bathroom and he’s not responding to me
at all.
[location and phone verification performed]
EMD: What’s the problem, tell me
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JASON KIRIAKA
A
exactly what happened?
Caller: I don’t know, I was... I heard
a crash. Um, I heard a moan. My husband did not respond. I got up and went
into to the bathroom to look. He’s not
responding to me all. He is breathing.
But we are afraid to move him.
EMD: How old is he?
Caller: My husband? He’s 63.
EMD: Is he conscious?
Caller: No.
EMD: Is he breathing?
Caller: Yes.
This call demonstrates an obvious
dilemma regarding correct Chief Complaint selection when confronted with
unwitnessed information. What part of
this information suggests an accidental
“fall” and what part suggests a medical
“collapse?”
The EMD in this case selected Protocol 17 - Falls. Several consultants and
EMD instructors did also. However,
nearly every lay person that heard the
tape
picked
Protocol
31
Unconscious/Fainting as the Chief Complaint. Why? Because they were not
being influenced by a protocol-based
notion that is not in sync with the statistical reality of this situation.
In this case it would be fair to ask,
“What difference does it make?” Both
protocols prompt DELTA-level (priority
emergency) codes that would more than
likely generate the same maximal
response conf iguration. If response
was the only issue, the selection of
either protocol would be clinically
sound. However, in addition to
response, protocol selection also influences scene and patient safety, information provided to responders, and
instructions provided to the caller. The
precise categorization of such cases can
have a profound effect on the notions of
”trauma“ safety such as moving the
patient, beginning and performing air9 - 1 - 1
M a g a z i n e
FROM MPDS V11.1 © NAEMD. USED WITH PERMISSION.
Protocols 17 [above] and 31 [above, right] of the Medical Priority Dispatch System. New research indicates that Protocol 17 ("Falls") should
be used for known falls while unwitnessed ground-level falls in which the patient is not conscious should be processed under Protocol 31
("Unconscious/Fainting.")
way maneuvers, and even at what point
the call is terminated by the EMD.
We know from available cardiac
arrest quotient (CAQ) data that approximately 50% of patients found in arrest at
the scene are predicted by 9-D-1 and 9D-2 dispatch codes. Many other Chief
Complaint Protocols also predict cardiac
arrest, with the DELTA tier capturing
nearly 88%. The selection of these protocols is similar to what most clinicians
would guess. The primary ones are, in
order of frequency: 9 (Cardiac Arrest),
31 (Unconscious/Fainting), 6 (Breathing
Problems), 32 (Unknown Problem/Man
Down) and, 10 (Chest Pain). Quite
unexpectedly, however, 17-D-3 (FallsNot Alert) ranked in the top 5% of determinant codes for CAQ likelihood. No
one had predicted this new f inding
because Falls are generally regarded, and
categorized, as traumatic incidents.
Falls are generally perceived to cause an
injury, not to be the result of a medical
event. In its defense, the MPDS does
address correct chief complaint selection
with Protocol 17’s first Key Question:
“What caused the fall?” However, this
probably does not capture a medical
“cause” very often and, as a result, medical problems are likely missed more
commonly than previously expected.
In the case example above, the caller
used the word “unresponsive” several
times, which is a good description of a
truly comatose patient. From a medical
point of view, it would be very unlikely
that the mechanism of injury from a
ground-level fall would be sufficient to
cause prolonged unresponsiveness.
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Although not impossible, such a situation
would be quite rare. Another point worth
mentioning is the false perceptions of
sudden unconsciousness so many of us
have acquired from watching years of
cowboy, action, and police shows on television. The ease with which TV characters are “knocked out” is simply amazing. Getting “bonked on the head” is not
usually sufficient to knock people out much less keep them out.
While this might cause an initial collapse, it would likely evolve into either a
cardiac arrest situation (not breathing or
agonal breathing) or a decreased level of
consciousness that would likely, and
somewhat quickly, improve to some
degree. A very brief seizure-like period
might accompany the event but if the
collapse was unwitnessed, it probably
would not have been seen or discovered
by the caller.
An unwitnessed, ground-level fall should be considered medical in nature [Protocol 31 - Unconscious/Fainting (Near)] when the patient is discovered to be unconscious or not alert on Case Entry.
While the single-blow, low mechanism head trauma commonly seen on TV
might certainly cause significant injury
and perhaps even momentarily daze the
victim, the expectation that such a blow
would “knock them out cold” is unrealistic (blows to the head with heavy, solid
objects are obvious exceptions).
Diagnostically, the actual cause of
the case we began with could only result
from a few, real-life, clinical scenarios:
1) The patient slipped, hit his head
very hard, and was completely unconscious. While certainly possible, it is
unlikely that head trauma caused by
ground-level fall would be sufficient to
cause prolonged unresponsiveness.
2) The patient suffered a sudden,
non-perfusing cardiac ar rhythmia.
3) The patient had a seizure. This
would also cause initial collapse and
unresponsiveness. The patient would
likely be breathing regularly, (although
predictably noisily), and would slowly
recover from her/his unconscious, postictal condition. However, it would be
statistically more possible than not for
the caller to have observed and reported
tonic-clonic, convulsive activity that
would commonly be present for 45 to 60
seconds. In the case presented, this
might account for the reported noise
accompanying, and immediately following, this initially unwitnessed event. In
addition, a family member or friend
caller would likely mention that the
patient was an epileptic or had experienced seizures before.
9 - 1 - 1
M a g a z i n e
4) The patient suffered a catastrophic,
intracranial event (hemorrhagic CVA,
berry aneurysm). This type of stroke
often causes a sudden, initial collapse
followed by true coma and a breathing
state that could remain regular, if
uncompromised by the patient’s airway.
If the event was massive and sudden
enough to cause a direct fall, it would
likely result in a deteriorating state of
breathing, from regular to irregular,
eventually leading to respiratory arrest.
The later is the most likely scenario
in the case presented at the beginning of
this article. While the 63-year-old age
of the patient is consistent with all of the
above scenarios, a large stroke, caused
by sudden, massive intracerebral (in the
brain) or intracerebellar (in or near the
brain stem) bleeding, is clearly the “rule
out” diagnosis of choice in this case.
The near immediate unconsciousness
reported by the caller does not bode well
for the ultimate survival of such patients
who usually die within the first several
minutes or hours, despite medical intervention.
How might protocol selection be
influenced if the event was witnessed?
It shouldn’t be unless it is very clear that
the origin of the patient’s fall was clearly
accidental (mechanical) rather than medical. If the origin of the fall was not
known, and the immediate state of the
patient’s level of consciousness was
decreased or absent, a medical cause
should be assumed and Protocol 31
[Unconsciousness/Fainting (Near)]
should be selected. A long fall involves
a high mechanism of injury and should
always be categorized using Protocol 17.
Our Research & Standards Division
believes there is a need to define a new
paradigm, which might be stated using
the following Rule:
“An unwitnessed, ground-level fall
should be considered medical in nature
[Protocol 31 - Unconscious/Fainting
(Near)] when the patient is discovered to
be unconscious or not alert on Case
Entry.
A related “Proposal for Change” will
be submitted to the National Academy of
Emergency Dispatch’s Medical Council
of Standards for their review and evaluation. In the meantime, be aware that
sudden unconsciousness caused by a
ground-level fall is rare and should warrant a significant amount of “medical
N o v e m b e r / D e c e m b e r
2 0 0 3
cause” suspicion when selecting the
Chief Complaint.
The outcome of the case presented
was fatal. The patient was first breathing noisily and, as he remained wedged
between the toilet and bathtub, he slowly
stopped breathing before he was finally
moved and CPR PAIs were given. ■
Jeff Clawson, MD, is considered the father
of modern emergency medical dispatch
and is the inventor of the priority dispatch
protocol systems concept. He is the
founder of the non-prof it National
Academies of Emergency Dispatch, the
largest certifying and standard-setting
public safety organization in the world,
with 33,000 members in 20 countries.
Brett Patterson is an Academics and
Standards Associate for the National
Academies of Emergency Dispatch. He
also serves as the Academy’s Council of
Research Chairman and Board of
Curriculum Editor. He can be reached at:
Brett@emergencydispatch.org.
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